PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: The washroom located on the second floor has approximately 20-30 paint chips exposing the inner wall.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: July 8, 2022
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation: A PIC's medication was found in the tub room located on the second floor.
Corrective Action(s): Ensure that all medications are safely and securely stored.
Date to be Corrected: July 8, 2022
STAFFING: 32050 - RCR s.37(1)(e) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Review of six staff files found one without evidence of immunization status and tuberculosis screening.
Corrective Action(s): Ensure that all employees provide evidence of compliance with the Province's immunization and tuberculosis control programs.
Date to be Corrected: July 8, 2022
STAFFING: 32110 - RCR s.40(1)(b) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection 40(2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: Review of six staff files found that 2 of 6 did not have evidence of a current performance appraisal on file.
Corrective Action(s): Ensure that the performance of each employee is reviewed regularly.
Date to be Corrected: July 8, 2022
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: Review of the facilities narcotic drug count sheets had inconsistencies whereby for example the second nurse signature/initials was not documented. Further discussion with leadership confirmed that two signatures/initials are required.
Corrective Action(s): Ensure that all employee's comply with the policies and procedures of the MSAC.
Date to be Corrected: July 8, 2022
CARE AND/OR SUPERVISION: 34570 - RCR s.75(3)(b) - If a restraint is used under section 74(1)(b) and the use of the restraint continues either continuously or intermittently for more than 24 hours, a licensee must (b) as part of the reassessment, consult, to the extent reasonably practical, with the persons who agreed to the use of the restraint.
Observation: Review of 3 of 10 PIC's care plan indicated use of a restraint however, the restraint agreement form found in the care plan was not reassessed since February 26, 2021, May 27, 2021 and June 2, 2021 and no documentation was found to confirm this review.
Corrective Action(s): A licensee must ensure reassessment includes consultation with the persons who agreed to use the restraint.
Date to be Corrected: July 8, 2022
CARE AND/OR SUPERVISION: 34740 - RCR s.81(4)(a) - A licensee must ensure that (a) the implementation of each care plan is monitored on a regular basis to ensure proper implementation.
Observation: Review of 1 of 10 PIC's care plan found a risk agreement which was not assessed quarterly as indicated on the form.
Corrective Action(s): Ensure that each care plan is monitored on a regular basis to ensure proper implementation.
Date to be Corrected: July 8, 2022
HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: A review of 4 of 10 PIC's care plans found the following:
- 3 PIC had no evidence of immunization status
- 4 PIC had no evidence of tuberculosis screening
Corrective Action(s): Ensure that all persons admitted to a community care facility comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: July 8, 2022
MEDICATION: 36170 - RCR s.72(b) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (b) the expiry date on the medication has passed.
Observation (CORRECTED DURING INSPECTION): Inspection of the medication cart found two expired medications.
Corrective Action(s): Ensure that a person's in care medication is returned the pharmacy if the expiry date on the medication has passed.
Date to be Corrected: June 15, 2022
RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: A review of 1 of 10 PIC's health records found no consent to receive medical treatment.
Corrective Action(s): A licensee must have and keep a person in care's records consent in writing from the person in care or representative of the PIC of when to call a medical practitioner in case of accident or illness.
Date to be Corrected: July 8, 2022
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection 83(5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: Review of 4 of 10 PIC's weight charts determined that a weight was not captured for the month of April and there was no documentation provided to explain why the weight was missing.
Corrective Action(s): Ensure that each person in care is weighed at least once a month or provide a reason as to why the weight could not be obtained.
Date to be Corrected: July 4, 2022
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